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To the Editor:

We read with great interest the article from Biviano et al.1 We think that their findings are of utmost importance for the prognostic assessment of patients following transcatheter aortic valve replacement. In this study, the rate of new-onset atrial fibrillation (AF) as reported in the ECG performed at discharge was 6%. This rate is low in comparison with previously reported research,2,3 especially if we consider the high rate of transapical approach in this population, which has been previously related to higher incidence of the arrhythmia.2,3 Still, the impact from these results cannot be underestimated, given the clear relationship with 30-month and 1-year mortality. Nevertheless, it is worth noting that the lack of differences in the rate of stroke/transient ischemic attack between groups may suggest the presence of confounding or underexplained factors. Although information concerning anticoagulant therapies was not reported by the authors, as they pointed out in the limitations paragraph, their use can probably help to understand the conclusions. First, the lack of inclusion in the sinus rhythm (SR)/AF group of short AF episodes that may have occurred during the hospitalization implicates their inclusion in the SR/SR group. This is a major issue because anticoagulation in short episodes is initiated less often.2 Second, although the lack of use of anticoagulation in the SR/SR group may have increased the rate of stroke, its more extended use in SR/AF group could have potentially lead to higher rate of bleeding events, with an associated increased mortality rate. Finally, patients in the SR/AF group received more often new pacemaker, what may have lead to better monitoring of AF episodes and higher use of anticoagulation, increasing bleeding risk.

In conclusion, anticoagulation is a main actor following transcatheter aortic valve replacement procedures to understand their outcomes. In the present study, a paradoxical effect of anticoagulation can probably explain the lack of differences in stroke rate (underprescribed in patients with short AF episodes) and also the higher mortality in patients with AF after discharge through an increased rate of bleeding events.